Why CIRAS is so important for blame-free reporting

This article takes a closer look at some of the lessons we can learn from the tram accident at Sandilands – in particular, what it means for safety reporting. Seven people died and 51 were injured on 9 November 2016 when a speeding tram overturned on a bend.

It is possible that this accident could have been prevented if reports about the risk of overturning had surfaced earlier.

Where internal reporting fails to address safety risks, a confidential reporting channel like CIRAS is often able to resolve matters to the satisfaction of all parties.

We have always been consistent with our messaging here: if you feel you can’t report internally, for any reason, or you’ve tried but the response had been unsatisfactory, you can always approach CIRAS.

We’re here to listen and facilitate a resolution.

Many reports to CIRAS make a tangible difference to health and safety when all else has failed. Please note that the article below has been written by Richard Booth, an independent CIRAS committee member, the views expressed in this article are those of the author and do not necessarily reflect those of CIRAS.

TOL (Tram Operations Limited) is now a member of CIRAS, but at the time of the accident they were not.

Drivers were hesitant to report errors to their supervisors, but a CIRAS report, by just one driver, might have alerted TOL to the risks of overturning.

In fact, the Rail Accident Investigation Branch (RAIB) report (December 2017) highlighted that: “…a Croydon tram driver contacted CIRAS on 4 March 2013 about a concern they had about fatigue arising from TOL’s roster.In response, TOL reported to CIRAS that rosters are only implemented following consultation with trade unions and the completion of an assessment of the roster using the HSE’s fatigue risk index (FRI). On this occasion TOL stated that the FRI assessment had not identified any areas of concern with the 2013 roster.”

In summary, CIRAS had been used by a concerned member of staff previously, but not specifically to highlight the risks of overturning and there had been no active promotion of the scheme at the time of the report.

Underestimating the risks

The tram overturned attempting to negotiate a very sharp curve at 45 miles per hour (mph) compared with a speed limit of 12 mph. It was thought the risks would be sufficiently controlled by a driver’s training and experience in conjunction with speed limit signs.

The RAIB report noted: “The only warning provided to tram drivers approaching the curve at Sandilands in darkness was a sign that was not visible until the driver had passed the point at which the tram’s speed could [only] be reduced to the required speed by application of the hazard brake. No other mitigation, other than drivers’ route knowledge, was provided against the risk of travelling around the curve at excessive speed.”

Moreover, three tunnels immediately before the turn perhaps acted as a disorientating ‘error trap’ and the driver may have lost his sense of awareness. Reporting without fear of retribution FirstGroup (the parent company of TOL) had in fact, a telephone confidential hot line. The RAIB infers that no driver contacted it.

If so, there are plausible reasons: it might not be perceived as sufficiently independent, and perhaps difficult to use in confidence (as the hot line also seems to be a non-confidential facility). Confidentiality is assured at CIRAS and their independent expert team reviews both the report and the organisation’s response.

The original report can therefore be closed out to the satisfaction of all parties. CIRAS exists because a ‘just culture’ is a vital aspiration but can ‘never’ be wholly relied upon. CIRAS exists essentially for two purposes.

First, to allow reporters with concerns to raise issues that have not, in their view, received attention in their companies (about 75% of CIRAS reports). Secondly, to encourage reporting by staff who may feel inhibited to talk to their employers, for whatever reasons.

What matters is that, as this post suggests, reporting to CIRAS may prevent bad events, and conversely that non-reporting may lead to managers living in a fools’ paradise.

A further benefit of CIRAS reporting is that it obliges companies to reflect on the concerns that have been brought to their attention. It can only be speculation what might have been different if just one TOL driver had made a report to CIRAS.

With all the variables involved, perhaps nothing. But it is the generality that matters. CIRAS is a ‘long stop’ that plays a major part in improving communications and feedback in the transport industries. It is valued by member companies.

Managers may reasonably believe that all is well, but a CIRAS report may reveal a more realistic perspective.

The RAIB report focused on the breakdown of communications between drivers and their supervisors at an operational level. But the deficiencies on the Croydon route were also a consequence of long standing fallible decisions, notably the apparent non-involvement of the drivers in risk assessments. TOL’s response to a ‘fatigue’ concern mentioned above was to emphasise trade union involvement.

Why were drivers not involved in the assessments?

I would personally welcome more CIRAS reports on topics that go to the root of transport safety management, in this case participation in risk assessments. For my conclusion is that the drivers knew far more about the hazards on the line than their managers.

KEY POINTS

You can help prevent an accident. If you’re a frontline worker, you are likely to have an in-depth understanding of the risks.